Select Committee on Public Accounts Fifty-First Report

Conclusions and recommendations

1.  Insufficient progress has been made in achieving the Department's plans in Building a Safer NHS for Patients. In particular the National Patient Safety Agency was very late in delivering the National Reporting and Learning System and has provided only limited feedback to NHS trusts on solutions to reduce serious incidents. The National Patient Safety Agency has also failed to evaluate and promulgate solutions that have been developed at trust level. As a result the Agency has yet to demonstrate good value for money.

2.  Trusts estimated that on average around 22% of incidents and 39% of near misses go un-reported, and that medication errors and incidents leading to serious harm are the least likely to be reported. The National Patient Safety Agency should compare its own data with the incident reporting data collected by the National Audit Office. It should bring together trusts with low levels of reporting and those that have achieved high reporting rates to help improve incident and near miss reporting. The Healthcare Commission should evaluate compliance with reporting requirements as part of its performance assessment process.

3.  The lack of accurate information on serious incidents and deaths makes it difficult for the NHS to evaluate risk or get a grip on reducing high risk incidents. The National Patient Safety Agency needs to obtain a more precise understanding of the extent and causes of death and serious harm. To do so, it needs to collect information on the contributory factors and develop a more targeted, risk based, approach to solutions aimed at reducing such incidents.

4.  Doctors are less likely to report an incident than other staff groups. The National Patient Safety Agency has run a national initiative to encourage reporting by junior doctors, and should promulgate the lessons from this initiative across the NHS. Trusts should evaluate their own levels of under-reporting and target specific training and feedback at those groups of staff that are less likely to report.

5.  Although most trusts stated their safety culture had become more open and fair, less than half of trusts had conducted a formal assessment of progress. In 2004, 23% of trusts felt they had an open and fair culture throughout their organisation, and another 72% felt their safety culture was predominantly open and fair. By 2005, the percentage of trusts rating themselves as having an open and fair culture throughout had increased to 32%, while those judging their culture only predominantly open and fair had reduced to 65%. All trusts should assess their safety culture using one of the established tools, such as those listed in the National Patient Safety Agency's guidance Seven steps to patient safety, and implement action plans to address the issues identified.

6.  Disciplinary action may be an appropriate response when patient safety is at risk, but the perception amongst nursing and other non-medical staff is that they risk suspicion if they report a serious incident. Our predecessors' Report on the management of suspensions (HC 296, 2003-04) identified an over-reliance on disciplinary measures. The Department still does not monitor the nature and length of non-medical staff suspensions, or the management action taken on them. The Department and NHS trusts should act on the previous Committee's recommendation to extend the role of the National Clinical Assessment Service to cover all staff.

7.  Patient safety alerts and other solutions are not always complied with though trusts self-certify that they have implemented them. For example, the Chief Medical Officer's 2004 report found that 50 days after the deadline for implementing a safety alert on oral methotrexate, only 54% of organisations had completed the actions required to reduce harm. In evaluating trusts' self assessments the Healthcare Commission with the Standards for Better Health should require trusts to provide evidence on the extent of compliance. During inspection visits they should evaluate and report on how well alerts and other solutions have been put into practice.

8.  Only 24% of trusts routinely inform patients involved in a reported incident and 6% do not involve patients at all. Only 69% of trusts had criteria for staff to follow. Using the National Patient Safety Agency guidance on Being Open, all trusts should as a matter of course inform patients and their carers if they have been involved in an incident, even if they suffered no harm. Patients and carers should also be consulted to help identify solutions.

9.  It took until July 2005, for the National Patient Safety Agency to produce its first feedback report to trusts on the number of incidents reported and some specific solutions to particular types of incidents. The Department should hold the National Patient Safety Agency to their commitment to produce feedback reports at least quarterly. These feedback reports should include illustrative business cases to demonstrate the cost-effectiveness of implementing solutions to specific problems.

10.  The National Reporting and Learning System has not, as hoped, helped simplify the complexity for trusts in reporting incidents. The Department, NHS Connecting for Health and the National Patient Safety Agency should agree a plan and timetable for rationalising the reporting routes so that within the next two to three years trusts need make only one report of an incident, which is then automatically distributed to the relevant organisation.

11.  To choose between hospitals under the NHS Choice agenda, patients will need access to robust information on patient safety, including comparable information from independent sector providers. The National Patient Safety Agency anonymises the data it collects and was not tooled up to provide comparable information. The Department needs to agree whether and how such information will now be provided and who will be responsible for publishing the data.

12.  The taxonomy of the National Reporting and Learning System differs from many local trust descriptions and classifications of incidents and also from taxonomies used by other countries. The World Health Organisation is developing an international taxonomy. The National Patient Safety Agency should either adopt this taxonomy or align its taxonomy fully to it, though with scope to meet additional requirements that the Agency may deem necessary.

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Prepared 5 July 2006